The majority of CDI programs rely on the query process as the fundamental hallmark of documentation improvement. This query process has steadfastly maintained its stature in the industry as the bell weather for CDI for over twelve years. Recent conversation with several CDI professionals has increased my confidence that early adopters to change in present CDI query processes are finally seeing the light, recognizing the need for CDI redesign and reposition in order to achieve leading edge results in achieving clinical documentation excellence.
Clinical documentation improvement, recently changed to clinical documentation integrity, does not clearly capture and represent the essence of what the profession can accomplish with well designed processes that support achievement of clinical documentation excellence. Clinical documentation excellence can be defined and understood as the medical record serving as a communication tool for physicians, telling the patient story in sufficient detail that an outside reviewer can clearly understand and see the 8Ws of physician documentation functioning as the standard of communication of patient care. The 8Ws are as follows:
What is wrong with the patient?
Where has the patient been?
Where is the patient now?
What is the physician thinking?
Why is the physician thinking?
Where is the physician going?
What is the physician going to do when he gets there?
What alternate plans does the physician have for plan of care?
Solid complete physician documentation is clear, concise, consistent and contextually correct, accurately reporting and reflecting the clinical information, clinical facts and context supportive of medical necessity and the need for hospital level of care. The tendency of the electronic health record to contribute to note bloat is real, yet it doesn’t have to be this way. Physicians can take control of the electronic health record as opposed to the other way around by learning the standards of documentation. CDI professionals adequately equipped with the capabilities and knowledge of these best practice standards and principles of documentation can be a formidable partner in working with physicians to achieve clinical documentation excellence. The first step is for the CDI professional to recognize the need to expand his/her skill set and core competencies in the standards and principles of documentation, taking the initiative to learn about and become more proficient in the ability to recognize insufficiencies in physician documentation and have the confidence level to address and discuss with the physician.
How to get started - The first logical approach to get started in the exciting journey to CDI conquering and mastering the standards of documentation is to converse with physicians and discover what the physician’s documentation pain points are, what do they need assistance with in becoming more adept at charting, thereby allowing for more time doctoring in front of the patient and less time doctoring in front of the computer? What challenges do physicians face in documenting in the EHR that we can be of great assistance? To this end the CDI professional will learn to understand and appreciate the burdens physicians face in effectively charting in the record, certainly explaining the excessive copy and paste found in the progress notes that bog down the medical record with unactionable often superfluous inaccurate clinical information that detracts from quality patient car